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Blank Copy of a Job Application

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									                                      JOB APPLICATION FORM                                                  1

      Position Applied For:- _____________________________________________________________________


Full Name:-______________________________________________________________________________

Address:- ______________________________________________________________________________

Contact Telephone Number/s____________________________________________________________

Are you legally eligible for employment in the UK (if you are unsure please seek advice from Company
Management:- __________________________________________________________________________

Do you have a current full driving licence?                          Yes           No

Driving licence valid from:-__________________ To:- __________________

Number of Penalty Points (if any) endorsed on current licence:- ______________________

Have you ever been disqualified from driving, or had motor insurance refused?           Yes        No

If “Yes”, please provide brief details_________________________________________________________

A copy of your driving licence must be provided upon offer of position and any changes to be reported
immediately. Please note a copy of your driving licence must be provided every 6 months along with a
copy of your current car insurance (if using your own car during to make calls to service users)

EDUCATION – please continue on a separate sheet if necessary.
From To      Name of University, College,       From To                  Name of University, College, Place of
             Place of Further Education i.e.                             Further Education i.e. training
             training establishment                                      establishment

Examination results/qualifications obtained please detail any qualifications/certificates you hold along with
the date obtained you feel may be relevant to the position applied for.
                                 JOB APPLICATION FORM                                                 2

Name and Address of Current Employer (or last      Job Title and Main Duties       Employment Dates
Employer if currently unemployed)                                                  From     To

Reason for Wanting to Leave/Leaving:                Average gross pay: £
                                                    per hour/week/month
Previous Employment (Employer Name, Address and your Job Title and dates of employment)
for a Minimum of 10 years
please continue on a blank sheet if necessary, ensure any gaps in employment history are explained.
1.                                                                                 From          To

2.                                                                                 From         To

3.                                                                                 From         To

4.                                                                                 From         To

5.                                                                                 From         To

6.                                                                                 From         To
                                     JOB APPLICATION FORM                                                   3

7.                                                                                      From           To

8.                                                                                      From           To

9.                                                                                      From           To

Notes to explain gaps in employment history (please continue on a blank sheet if necessary):-

Prepared to Work:        Full-Time        Part-Time
Details of any other work which you will continue to undertake if you are offered this Job Position:

Please provide details of any outstanding holidays to be taken:

Available to take employment from:-

Through the 1975 exemptions Order of the Rehabilitation of Offenders Act, 1974, and by virtue of the nature
of the post for which you are applying, we are obliged, as your prospective employers, to ask the following
question. Any information supplied by yourself will remain confidential and considered only in relation to
the Job Application:

With the exception of minor motoring offences, have you ever been convicted of any criminal offence by
a Court of Law?

YES       NO
If “YES” please provide brief details of the offence(s) and relevant dates:
                                    JOB APPLICATION FORM                                                       4

 All positions are subject to a Criminal Records Bureau checks (Enhanced)


 The organisation seeks to recruit employees on the basis of their general suitability for a position and aims to
 ensure that consideration of age, sex, marital status, disability and racial or ethnic origin should play no part
 in this process.

 In order to monitor the effectiveness of this commitment to equal opportunities it would be helpful if you
 could complete this section of the form. Completion is not compulsory but should you give details below
 the information will be used for no other purpose than that as stated in this paragraph.

 Marital Status          Single    Married     Separated      Widowed       Divorced

 Sex                     Male      Female

 Ethnic Origin           African   Afro-Caribbean      Mixed Race       Asian     European

 References :-

 We will require at least two written references, from people you are not related to, one of which must be
 your current or most recent employer:-

 Reference One:-

 Name of Referee :-     ______________________________________

 Position:-             ______________________________________

 Company Name:-         ______________________________________

 Company Address:-      ______________________________________



References :-

Reference Two:-

Name of Referee :-     ______________________________________

Position:-               ______________________________________
  DECLARATION - please read carefully ensuring 10 year employment history is complete and any gaps
  explained in full, then sign and date your application:
Company Name:-           ______________________________________
I certify that to the best of my knowledge, the information in this application form is correct and complete.
I agree Address:- ______________________________________
Companythat any deliberate omissions, misrepresentations or falsification of the information in this


                                    JOB APPLICATION FORM                                                  5
application form will be grounds for the application to be rejected, or possibility of subsequent discharge
once employed by the Company. I understand that if employed by the Company this form may be filed
on computer and/or in manual records and will be made available to visiting inspectors as necessary.

Applicant’s signature:- _______________________________________

Date:-                 ________________________________________

  Office Use:-

                                                    Medical History

         Has your employment ever been
         terminated on the grounds of ill health?               YES                     NO
         Approximately how many days sickness
         have you had in the past 12 months?
         What is your height?
         What is your weight?
         What is your weekly alcohol
         Do you smoke?
         Are you currently taking any prescribed
         Are you currently under the care of a
         doctor or other medical professional?

         Are you currently suffering from of have suffered from, any of the illnesses listed:-
         Lung Disease                                          YES                      NO
         Heart/circulatory illness/hyperventilation            YES                      NO
         Diabetes                                              YES                      NO
         Asthma                                                YES                      NO
         Hayfever/allergies                                    YES                      NO
         Bronchitis/Pneumonia/Pleurisy                         YES                      NO
         Tuberculosis                                          YES                      NO
         Epilepsy/Frequent fainting/blackouts                  YES                      NO
                            JOB APPLICATION FORM                                                         6
 Headaches Migraines                                   YES                    NO
 Psychiatric illness/anxiety/depression                YES                    NO
 Dermatitis/skin sensitivity                           YES                    NO
 Back/neck problems                                    YES                    NO
 Recurrent Infections                                  YES                    NO
 Hepatitis/jaundice                                    YES                    NO
 Stomach/bowel trouble                                 YES                    NO
 Joint problems                                        YES                    NO
 Severe stress reaction                                YES                    NO
 Depression/anxiety                                    YES                    NO
 High blood pressure                                   YES                    NO
 Hernia or rupture                                     YES                    NO
 Kidney/bladder problems                               YES                    NO
 Hearing/sight problems                                YES                    NO
 Mobility problems                                     YES                    NO
 Serious accident                                      YES                    NO

If you have answered “YES” to any questions in this section, please give details and dates where
relevant; this is important, especially where you have a qualifying disability under the Disability
Discrimination Act 1995, as it will enable us to identify what, if any “reasonable adjustments”
need/can be made.

I hereby declare that the information given within the medical history section is full and true to the
best of my knowledge. I understand that if, later, it is discovered that I have knowingly withheld
medical information, disciplinary action may be taken against me, which may include dismissal.

Signature: ____________________________________________

Date:     ____________________________________________

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